Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 22 Advanced Practice...

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 22Advanced Practice Nursing: The Latest Issues and Trends


Role Definition• Advanced practice registered nurses (APRNs)

– Nurse Practitioner (NP)– Clinical Nurse Specialist (CNS)– Certified Nurse Midwife (CNM)– Certified Registered Nurse Anesthetist (CRNA)


Nurse Practitioners• RNs with advanced graduate education, clinical training• Provision of wide range of health care services

– Diagnosis and management of common and complex medical conditions

– Individuals of all ages


Clinical Nurse Specialist• RN with graduate degree in nursing as CNS• Expert clinician in specialized practice area• Working in variety of settings• Provision of direct patient care• Provision of expert consultation• Implementation of improvement in health care delivery systems• Integration of nursing practice with medical diagnosis and

treatment of disease, injury, and disability


Certified Nurse Midwife• Primary care for women across the lifespan

– Special emphasis on pregnancy, childbirth, and gynecologic and reproductive health

– Also inclusion of male partners for sexually transmitted infections

– Care of the normal newborn during the first 28 days of life

– Focus on special needs of women• Graduation from nurse midwifery program; successful

completion of national certification examination


Question

Is the following statement true or false?• A master’s degree is required to become a clinical nurse

specialist.


Answer

True.• To be a clinical nurse specialist, the nurse must have

graduate preparation, a master’s or doctorate degree, in nursing.


Certified Registered Nurse Anesthetist• Licensed professional nurse; provision of same

anesthesia services as anesthesiologist• Administration of anesthesia in 4 general categories

– Preanesthetic preparation and evaluation– Anesthesia induction, maintenance, emergence– Postanesthesia care– Perianesthetic and clinical support function


Background of APRNs• Continuing high numbers of errors requiring nurses with

advanced degrees to remain in practice • Nursing as a key profession to lead way to significant

change to the health care system• Lack of enough doctoral nurses impacting achievement of

patient-centered, cost-effective, and safe health care system

• Reasons for not pursuing advanced degrees– Salary discrepancies– Length of time for degree– Costs for returning to school


Background of APRNs (cont.)• Need for research by PhD-prepared nurses, clinically

active professionals with a background in policy, leadership, and organizational behavior

• Landmark reports: AHA Commission on Workforce for Hospitals and Health Systems; Joint Commission on Accreditation of Healthcare Organizations; Robert Wood Johnson Foundation

• AACN task forces


Doctor of Nursing Practice (DNP)• Research-focused• Practice-focused

– Nursing practice (direct care, care management, nursing and health care organization administration, health policy development and implementation)

– Practice doctorate: highest level of nursing practice


Doctor of Nursing Practice (cont.)• First program at Case Western Reserve University (1979) as

doctor of nursing (ND); recently converted to doctor of nursing practice (DNP)

• Practice doctorate (DNP, ND) vs. research doctorate (PhD, DNS/DNSc)

• Research doctorate: scientific content and research methodology; original research project; dissertation

• Practice doctorate: innovative, evidence-based practice reflecting credible research

• Both complementary, alternative approaches


Doctor of Nursing Practice (cont.)• Position statement on practice doctorate in nursing (DNP

as entry level for APRN)• The Essentials of Doctoral Education for Advanced

Practice Nursing – Provided schools with key content areas to be

included in DNP curriculum– Provided guidelines, standards for development of

courses (see Box 22.1)


Question

Is the following statement true or false? • A doctor of nursing practice degree is a research-, theory-

based degree.


Answer

False.• A doctor of nursing practice degree focuses on clinical

practice, not research or theory.


Thoughts of APRN Organizations • The National Organization of Nurse Practitioner Faculties:

acknowledgement that DNP worthwhile goal to attain• National Association of Clinical Specialists: neutral

position with ongoing dialogue• American College of Nurse Midwives: DNP an option but

not requirement for entry to practice• American Association of Nurse Anesthetists: support DNP

mandate with extension to 2025


Issues and Concerns• Timing of recommendation (other pressing issues)• Concern that DNP does not include theory• Impact of DNP on nursing education (PhD programs)• Concern about faculty with DNP and tenure• Apprehension related to rigor of DNP programs with other

doctoral programs


Question

Which of the following is being emphasized as the required degree for entry into practice for APRNs?

A. Master’s degreeB. PhDC. DNPD. DNS


Answer

C. • The current belief is that the DNP should be considered

as the degree required for entry to practice for APRNs.


Clinical Nurse Leader • ANA white paper of 2007 citing need for

– Preparation for clinical leadership– Implementation of outcomes-based practice, quality-

improvement strategies– Remaining in, contributing to profession– Creating, managing microsystems of care


Clinical Nurse Leader (cont.)• Increased pressure on nursing education to produce

graduates with education, expertise to meet challenges of 21st century

• Ten assumptions for preparing CNL (see Box 22.2)• Key area of focus: integration of care of all health care

providers


Clinical Nurse Leader (cont.)• Expectations:

– Provide, manage care – Critically evaluate, anticipate risks to client safety– Profile patterns of need, tailor interventions– Advocate for clients, community– Assume role of educator– Be responsible for care provision, management– Be member, leader of health care team


Clinical Nurse Leader (cont.)• Necessary skills

– Systems thinking– Risk analysis– Quality improvement at the micro- and mesosytem

level– Use of evidence-based practice– Ability to laterally integrate care over the health care

continuum


Clinical Nurse Leader (cont.)• CNS controversy

– Belief that CNL functions in manner similar to their practice

– CNL, CNS with overlapping roles, competencies • CNL: master’s-prepared advanced generalist nurse• CNS: master’s-prepared APN with specialty


Clinical Nurse Leader (cont.)• CNL role: all patients receive special attention across care

continuum, not just ones with certain diagnoses• Statement of case for the role:

– Humanize, personalize health care experience– Coordinator, change agent

• Role of CNL continues to be assessed in years to come


Question

Is the following statement true or false?• A CNL focuses on a specialty area of patient care.


Answer

False.• A CNL provides and manages care, integrating the care of

all health care providers. A CNL is considered to be an advanced generalist nurse. A CNS is considered to be an advanced practice nurse with a specialty.


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